ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION () GRID FOR MEDICAL BENEFITS FOR DIRECTLY CONTRACTED PROVIDERS ONLY Effective 01/01/2019 Before services are provided, please check: Member Eligibility Medical Group Benefit Coverage Contracted Provider Excluded Code QUESTIONS? Please call the Alliance Provider Services Department at 1.510.747.4510 Acupuncture NO Four (4) visits per month. Admissions (Inpatient, Long-term Acute Care (LTAC), Skilled Nursing Facility (SNF), Subacute) Allergy Services Bariatric Psychiatric Evaluations (Managed by Beacon Health Strategies) More than four (4) visits per month (clinical review required). First 10 visits per benefit year (self-referral). After 10 visits per benefit year. Allergen specific, each allergen is covered up to 50 units per patient annually; additional units would require medically necessary review. Biofeedback Policy Exception: only covered if part of a treatment plan for Pervasive Developmental Disorder (PDD) or autism. Blood Products CBAS (MLTSS Service) (SPD only) Chemotherapy please call Alliance Provider Services 1.510.747.4510 Page 1 of 8
Children s Developmental Evaluations Chiropractic Services Provided outside of a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC) for all members. Provided at FQHC and RHC two (2) visits per month for all ages. Provided at FQHC and RHC > two (2) visits per month for all ages. NO First 20 visits per benefit year (self-referral). After 20 visits per benefit year. 54150 newborn not a covered code; 54160-63 fall Circumcision under specialty surgery and require. Clinical Trials - Cancer Only Enhancing, altering or reshaping appearance Cosmetic Services through surgical and medical techniques. Custodial Care Dental Care (Refer to EOC for coverage criteria and exceptions) Non-covered Benefit (NCB) in the Alliance Managed Care (MCMC) contract; the Alliance covers month of admission and following month only AND must notify DHCS for disenrollment back to fee-for-service (FFS). For IV sedation and general anesthesia; services related to jaw preparation for radiation. General Dental: Carved-out to state Denti-Cal. Public Authority Phone Number: 1.510.577.3552 Diagnostic and Laboratory Services (Rendered through Quest Diagnostics) Dialysis Covered for home peritoneal dialysis or outpatient hemodialysis. please call Alliance Provider Services 1.510.747.4510 Page 2 of 8
NO DME/Medical Supplies Incontinence Creams and Washes (CHME) DME Incontinence - Diapers (CHME) Covered for chronic pathologic conditions that cause incontinence. Electroencephalography (EEG) Emergency Care/Treatment Enteral and Nutrition Formulas Experimental/Investigational treatments Facility Admissions (Emergency and Elective Inpatient, LTAC) Under 21 years of age: Cream and wash products are covered where there is a chronic pathological condition that causes incontinence. DME/ Repair EPSDT supplemental services Foot Orthotic CM for Out-of-Network (OON), coordination of care between practitioners, transferring medical information as necessary, complex care plans. Targeted CM (through RCEB); Behavioral Health members < 21 years of age; Home Health Nursing services. Covered with the diagnosis of diabetes. Podiatric devices to prevent or treat diabetes complications. \\aah-fileserv2\clinical\unit - Authorizations\Icontinence supply list MediCal\incontlist.xls \\aah-fileserv2\clinical\unit - Authorizations\Icontinence supply list MediCal\incontinent creams washes.xls CHME email: aaorders@chme.org Fax: 1.844.583.4049 \\aah-fileserv2\clinical\\unit - Authorizations\DME\ DME Frequency Codes Sep 2013.pdf CHME email: aaorders@chme.org Fax: 1.844.583.4049 Page 3 of 8
NO Genetic Testing Health Education Hearing Aids HIV Testing and Counseling Services Home Health Hospice Imaging (Specialty: nuclear medicine, radiation therapy) Place of Service: At Home Place of Service: Inpatient In-Office Injectable (Specialty drugs only, refer to the Alliance website for specific drugs) Infertility Treatment Infusion (Free Standing Infusion Centers) Laboratory Services Basic Maternity Admission (Coverage for infants) Mental Health Nutrition and Dietician Assessment/ Counseling (Both general and diabetic) Newborn is automatically covered under the mother the month of delivery and the following month. Covered for the first 30 days of life under the mother. Dependents are not eligible to enroll in. Mild to moderate only; severe carved out to county. : Covered in association of autism or Pervasive Developmental Disorder (PPD) or an emergency via emergency department (ED). Beacon Health Strategies Toll-Free: 1.855.856.0577 Page 4 of 8
NO OB/GYN in Network Orthodontics, Orthognathic and Appliance Therapy for TMJ Orthotics and Prosthetics Out-of-Network (OON) Outpatient Surgery and Specialty Procedures (Refer to the Prior Authorization List for specific procedures) Palliative Care Phenylketonuria (PKU) Foot orthotics with diagnosis of DM. Podiatric devices to prevent or treat diabetes complications. Breast Prosthetics: After removal of breast, external prosthetic plus three (3) bras/year. All services from non-contracted providers. OB/GYN professional services out of network (If qualifies for CoC, follow CoC process). Out of State Service: Coverage is allowed when postponing care or return to California would cause severe health problems. Out of Country: Coverage is allowed in Canada and/or Mexico. The testing and treatment of PKU are covered, including formulas and special food products that are a part of a diet prescribed by a physician or registered dietitian in consultation with a physician who specializes in the treatment of metabolic diseases. The testing and treatment of PKU are covered, including formulas and special food products that are a part of a diet prescribed by a physician or registered dietitian in consultation with a physician who specializes in the treatment of metabolic diseases. For a list of specific procedures please visit: www.alamemdaalliance.org Page 5 of 8
NO Provided outside of a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC) for all members. Provided at FQHC and RHC two (2) visits per month Podiatry for all ages. Provided at FQHC and RHC > two (2) visits per month for all ages. All ages: Clinic settings and conditions based on medical necessity. Preventative Care Preventive Health Screenings for: 1. DEXA Scan (osteoporosis) 2. Mammogram (breast cancer) 3. Colonoscopy (colon cancer) 4. Diabetes Screening (diabetes) 5. Immunizations (children/adult) Use the most recent QI Preventive Health Guidelines as criteria. Radiology (Musculoskeletal x-rays, chest x- rays, mammogram, echo, EKG, PFT, DEXA, ultrasound, etc.) Radiology (CT, MRI, MRA, PET) Reconstructive Surgery Reconstructive surgical services performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (A) To improve function; (B) To create a normal appearance, to the extent possible. For specific codes please visit: www.evicore.com Page 6 of 8
Rehab Second Opinion Requests (Out-of-Network Providers only) Sensitive Services (Including therapeutic abortion and HIV testing, and counseling STD testing) (Contracted and non-contracted providers) Outpatient Therapy (ST, OT, PT) not to exceed 60 consecutive calendar days per condition; additional services based on medical necessity. 60 day limit does not apply to Tx plans for autism or PDD. Tx plans will be reviewed every six (6) months. Cardiac: CPT 93797-98 or G0422-23 Pulmonary: (2) 1 hour sessions per day up to 36 sessions (additional 36 sessions per medically necessary for max of 72 total). Acute Rehab: Evaluated by inpatient team as extension of admission. Vocational 100 days per benefit year. Skilled Nursing Facility Covered for the month of admission plus the next (Contracted month. Sleep studies Specialist Referrals (Within network) Standard Diagnostic Procedures (I.e. colonoscopy, mammogram, ECHO, EKG, PFT, DEXA, ultrasound, etc.) Substance Abuse Carved out to Alameda County Mental Health. NO Alameda County Mental Health (ACCESS) Phone Number: 1.510.346.1000 Toll-Free: 1.800.491.9099 Beacon Health Strategies Toll-Free: 1.855.856.0577 Page 7 of 8
Transgender Services Mental and behavioral health services, hormone therapy, surgery that brings primary and secondary gendered characteristics into conformity with the individual identified gender. NO Transplant Services The Alliance is responsible for all services related to kidney and corneal; all other transplants are DHCS fee-for-service. The Alliance is responsible for professional and evaluations, up to acceptance by the transplant program and must use DHCS Center of Excellence Transplant program. Transportation All major organ and bone marrow transplants that are not experimental/investigational in nature. Covered for: Emergency transportation, all levels; non-emergency medical transportation; non-medical transportation. Ground transportation by ambulance only for emergency. UV Light Vaccines - Preventative Health Vaccines - Travel Eye exam once every 24 months. Vision Cataract spectacles and lenses covered. LogistiCare Toll-Free: 1.866.791.4158 March Vision Care Toll-Free: 1.844.336.2724 Public Authority Phone Number: 1.510.577.3552 Page 8 of 8